Duodenum preserving resection of the head of the pancreas: a standard procedure in chronic pancreatitis

Duodenum-preserving resection of the head of the pancreas was developed 25 years ago by Beger. This procedure is indicated in patients suffering from chronic pain in combination with inflammation of the head of the pancreas, common bile duct obstruction, pancreatic duct obstruction and/or obstruction of the retropancreatic vessels. At the Inselspital in Berne, 74 patients underwent this operation between 1993 and 1996. The median length of the operation was 380 min, with the need for transfusion in a median of 0 units (0-6). There was no postoperative mortality. Total postoperative morbidity was 13%. One patient needed relaparotomy on day 17 for small bowel obstruction. Median length of hospital stay was 11 days. Postoperatively, two patients developed diabetes. Duodenum-preserving resection of the head of the pancreas represents an organ-preserving principle of surgery. This procedure treats the complications of chronic pancreatitis and provides long-term pain relief in more than 80% of patients.     

Ultrasonographic findings of diseases in peripheral lung fields using transtracheobronchial endoscopic ultrasonography (TUS)

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. The case of a 70 years-old woman with microcystic cystadenoma is reported. CT-scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An ERCP showed cephalic symmetrical stenosis (diameter 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter 6 mm). An intraoperative biopsy of the cystic wall was performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including the stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, in a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, DPPHR is a highly effective surgical procedure with a low early and late morbidity and mortality due to limited surgical resection. This technique, introduced into surgical practice by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can be performed also in case of pancreatic benign tumors, as microcystic cystadenoma. Advantages of this technique makes DPPHR an attractive alternative to Pylorus-Preserving-Pancreatico-Duodenectomy (PPPD).     

Characteristics and treatment of mucin-producing tumor of the pancreas

BACKGROUND/AIMS: There has been no thorough clinicopathological analysis of a large number of cases with mucin-producing tumor of the pancreas. The aim of this study was to investigate the clinicopathological features of and therapeutic strategy for this ailment. METHODOLOGY: Two hundred and fifty-nine cases of mucin-producing tumor of the pancreas were analyzed clinicopathologically. RESULTS: Mucin-producing tumor of the pancreas was found in 177 males and 82 females (M:F=2.2:1). The mean age was 65.5 years. Jaundice, diabetes mellitus and a past history of pancreatitis were found in 15-19% of the cases. The tumor was most frequently (62%) found in the head of the pancreas. Pathologically, hyperplasia or adenoma was found in 58 cases, and adenocarcinoma in 160 cases. Five-year survival rate by the Kaplan-Meier method was 82.6% in all of the cases, and the post-operative survival curve was much better in cases with this type of carcinoma than in cases with ordinary pancreatic duct cell carcinoma (5-year survival rate: 17.3%). Organ-function preserving procedures, such as duodenum preserving subtotal resection of the head of the pancreas or spleen preserving distal pancreatectomy, might be recommended for this disease without infiltration. CONCLUSIONS: Mucin-producing tumor has unique clinicopathological characteristics, such as the dilated main pancreatic duct or branches, dilatation of the orifice of the papilla of Vater, or a good prognosis. Organ-function preserving procedures should be recommended in some cases with this ailment.     

Duodenum-preserving pancreatic head resection--a standard method in chronic pancreatitis

In patients with chronic pancreatitis the inflammatory process in the pancreatic head is frequently the pacemaker of the disease. In these cases an inflammatory tumor develops which leads to local complications in half of the patients. Duodenum-preserving pancreatic head resection, contrary to procedures used in the past, offers the possibility to preserve stomach, duodenum, biliary tree, and the insulin secretory capacity. Duodenum-preserving pancreatic head resection is a subtotal resection of the pancreatic head. In a series of 380 patients the hospital mortality rate was 0.8%, the frequency of reoperation 5.3%, and the median hospitalisation time 13.9 days. The early postoperative glucose metabolism was deteriorated in 2% and improved in 9% of cases. After a median follow-up time of 6 years, 88% of the patients were completely painfree or suffered pain rarely. Sixty-three percent were gainfully employed; the late mortality was 8.9%. Only 10% of the patients had further bouts of pancreatitis. The decisive advantage of duodenum-preserving pancreatic head resection over Kausch-Whipple resection is preservation of the endocrine pancreatic function and of neighbouring organs.     

Modified duodenum-preserving resection of the head of the pancreas

A modified procedure of duodenum-preserving resection of the head of the pancreas was used in treating three patients with benign lesions in the head of the pancreas. Compared with Beger's procedure, the modified procedure was simpler, and pancreaticojejunostomy on duodenal side was not necessary because of less remaining pancreas attached to the conjunction of the pancreatobiliary duct. The patients, recovered and ate food from 4 to 6 days after operation without symptoms of duodenal obstruction. The patient's digestive function was normal, and the pre- and postoperative pancreatic endocrine function was almost identical. This procedure can be used as the first-choice surgical procedure for benign lesions in the head of the pancreas. Problems in how to protect blood supply of the duodenum were also discussed.     

Nonductal tumors of the pancreas. The importance of laparotomy

OBJECTIVES: To delineate the incidence of nonductal pancreatic neoplasms and determine whether distinguishing clinical or radiologic characteristics exist. METHODS: From 1977 through 1990, we examined 353 patients with a pancreatic mass as demonstrated on abdominal computed tomography or ultrasonography. Patients with chronic pancreatitis or functioning neuroendocrine tumors were excluded. All patients underwent operative exploration for histopathologic diagnosis and resection when possible. RESULTS: Adenocarcinoma of the pancreas was seen in 322 patients. The remaining 31 patients (8.8%) were found to have nonductal tumors of the pancreas, including nonfunctioning islet cell tumors (15), cystadenoma (nine), lymphoma (five), lipoma (one), and mesothelioma (one). These neoplasms were evenly distributed between the head and tail of the pancreas, while most of the ductal pancreatic carcinomas were located in the pancreatic head. While abdominal computed tomography and ultrasonography accurately identified most cystic neoplasms, the remaining nonductal lesions were indistinguishable from ductal pancreatic tumors. Preoperative biochemical studies and liver function tests failed to separate ductal and nonductal pancreatic masses. Average survival for patients with nonductal lesions was significantly longer compared with ductal tumors of the pancreas. CONCLUSIONS: Because increasing reliance on advanced radiologic and invasive nonoperative diagnostic testing may deny proper surgical therapy to patients with nonductal neoplasms of the pancreas, laparotomy and histopathologic diagnosis are advisable in most patients with an isolated pancreatic mass.     

Brief history of the Spanish Society of Microbiology. V. From 1987 to 1991]

BACKGROUND/AIM: The clinical presentation, pancreatographic findings, and outcome of patients with intraductal papillary mucinous tumours have not been reported in a large patient series in the English literature. This study reviewed 32 patients diagnosed between 1980 and 1994, with special attention to these features. PATIENTS/METHOD: Data on 24 operated and eight non-operated patients were abstracted from inpatient, outpatient, and procedure records. RESULTS: Acute pancreatitis was the most common presentation seen in 56% of patients. Relapses occurred during an average of 43 months before diagnosis. A patulous papilla was observed in 55% of the cases. Endoscopic pancreatography showed communicating cysts, a diffusely dilated main pancreatic duct, and amorphous defects in 42, 71, and 97% respectively. An invasive carcinoma was found in nine of 24 (37.5%) of operated patients: six of the patients (66%) died or developed metastases within three years after surgery. No mortality was related to the tumour in absence of invasive carcinoma. Benign recurrence on the remaining pancreas was unusual and occurred late after surgery. CONCLUSIONS: Intraductal papillary mucinous tumours must be considered in the differential diagnosis of relapsing pancreatitis. Despite slow growing, these tumours have an obvious malignant potential and a very poor prognosis when invasive carcinoma has developed. Early recognition and resection are the cornerstones of treatment.     

Treatment for dehiscence of pancreaticojejunostomy after pancreaticoduodenectomy: is resection of the residual pancreas necessary?

BACKGROUND/AIMS: Partial or total disruption of pancreaticojejunostomy (PJ) is a rare but serious complication after pancreaticoduodenectomy (PD). The recommended option of treatment is completion pancreatectomy. However, the mortality remains high as most patients were too critical to withstand the procedure. PATIENTS AND METHODS: 12 consecutive patients with dehisced PJ after PD were treated by oversewing the pancreatic stump without resection of the residual pancreas. RESULTS: Although a high morbidity rate (75%) occurred after our management, ten patients survived reoperation, without recurrent pancreatic fistula or the need for insulin injection. CONCLUSION: A complete pancreatectomy is not necessary for a dehisced PJ, if acute pancreatitis is not found in the residual pancreas.     

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. Pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.     

Basic principles of surgical policy in complicated chronic pancreatitis

The paper presents some experience with surgical treatment of 183 patients with complicated forms of chronic pancreatitis. The type of a surgical intervention depended on the pattern of pancreatic morphological changes. Operations of internal drainage of the pancreas in 103 patients with ductal hypertension provide the largest percentage (92.4%) of good and satisfactory results. Resectional methods of surgical treatment for chronic pancreatitis (n = 36) without signs of intraductal hypertension and with the prevalence of predominant lesions in some portions of the gland yield 80% good and satisfactory results. The incidence of postoperative complications following pancreatic resections is higher than those after drainages (16.2 versus 11.6%). The paper gives a concept of combined operations on the pancreas and bile ducts in chronic pancreatitis complicated by stricture of the distal common bile duct, revealed in 24.4% of cases.     

Surgical treatment of pancreatic head and periampullary tumors

The aim of this study was the comparison of the postoperative results of standard Whipple pancreatoduodenectomy (WP), pylorus preserving pancreatoduodenectomy (PPPD) and palliative bypass operation performed for treatment of pancreatic head and periampullary tumors. In the period from Jan. 1992 to 1996 106 patients had tumors located in the head of pancreas and 21 patients had periampullary tumors. The diagnosis was established by ERCP, transabdominal ultrasonography and computer tomography. We assessed the morbidity, mortality, prognostical data of the surgery of pancreatic head and periampullary tumors. Tumor markers such as CEA, CA 19-9 and CA 125 were also studied. The operability rate was 26% in case of pancreatic head tumors and 69% in peri ampullary tumors. The mortality rate was 6%. Postoperative complications were in 23 patients(18.1%). There was no significant difference between the survival of WP and PPPD group, but we found much better survival in patients with periampullary tumor. After palliative operation the survival rate was 6.1 months in case of pancreatic head carcinoma and 11 months in case of periampullary tumors. Our data provided many evidences about the advantage of PPPD in the patients with malignant periampullary and pancreas head tumors and the long-term results and quality of life is much better after PPPD.     

Cholesterol crystal embolization to liver, gallbladder, and pancreas

We retrospectively studied the clinical features of all 44 patients (35 men, 9 women, mean age 74.5 years) registered with a diagnosis of hepatic, biliary, and/or pancreatic cholesterol crystal embolization (CCE) in the Dutch National Pathology Information System (DNPIS) from 1973 through 1994. Liver CCE was found in 12 (11 autopsies and 1 biopsy), gallbladder CCE in 2 (resection specimens), pancreas CCE in 19 (18 autopsies and 1 biopsy), and both liver and pancreas CCE in 11 (all autopsies) patients. Five patients presented with focal liver cell necrosis, 1 with acalculous necrotizing cholecystitis, 1 with chronic cholecystitis, 10 with necrotizing pancreatitis, and 1 with chronic fibrosating pancreatitis. Four patients died of CCE-induced pancreatitis. Nineteen patients died as a consequence of other CCE sites. These were reported in 37 patients. All patients had a history of atherosclerotic vascular disease. In half the patients a possibly CCE provoking factor (vascular surgery and/or cannulation, anticoagulant treatment) was present. We conclude that liver cell necrosis, cholecystitis, and pancreatitis may be caused by CCE, particularly in elderly male patients with a history of atherosclerosis.     

Extended radical pancreatectomy for carcinoma of the head of the pancreas

BACKGROUND/AIMS: Pancreatic cancer has a poor prognosis, which is, in part due, to the unfortunately advanced stage, in which the tumor is diagnosed. Since 1973, we have utilized a unique method of extended radical pancreatectomy, using the translateral retroperitoneal approach (TRA) to facilitate combined portal resection. The advantages of this operation are described herein, for patients with carcinoma of the head of the pancreas. In addition, the problems associated with this operation are discussed. METHODOLOGY: Survival was calculated based on type of resection, degree of invasion of the retroperitoneal tissues, degree of lymph node involvement, and cancer stage. Extensive surgery has been performed for pancreatic carcinoma 216 patients. Of these, 14 patients had carcinoma of the head of the pancreas. There were 58 patients who underwent macroscopically curative resections. RESULTS: Only 39 patients were microscopically curative. Ten of the patients who underwent microscopically curative resections, survived for 5 years (34.0%). There were no statistically significant differences in survival based on tumor size. However, there was a significant difference in survival based on extent of invasion of the anterior capsule of the pancreas, extent of invasion of the retroperitoneal tissue, extent of lymph node involvement, cancer stage, and extent of invasion at the surgical margin of resection. CONCLUSION: The results suggest that extended radical pancreatectomy may be indicated for the treatment of cancer of the head of the pancreas.     

Acute myocardial infarction in a young woman with systemic lupus erythematosus

A 49-year-old diabetic patient with abdominal pain was found upon ultrasonography and computed tomography to have a cystic mass in the head of the pancreas with dilation of the main pancreatic duct. The head of the pancreas and duodenum were removed surgically. Examination of the operative specimen showed chronic pancreatitis, dilation of the main pancreatic duct, and impacted mucus in the secondary ducts with villous proliferation of the ductal epithelium, establishing the diagnosis of intraductal adenomatosis. There was no evidence of malignancy. The resection margin was involved, and consequently the remainder of the pancreas was removed six months after the initial surgical procedure. A review of the literature showed that intraductal adenomatosis tends to spread and carries a high risk of malignant transformation. Surgery is required because of the risk of pancreatic duct obstruction and pancreatic cancer. Intraductal adenomatosis of the pancreas shares many characteristics with other adenomatous proliferations of the gastrointestinal tract (colorectal villous adenoma, bile duct adenomatosis), including presence of villous structures with increased mucus production, a tendency to spread massively, and a high risk of malignant transformation.     

Analysis of the surgical treatment results in patients with acute pancreatitis

The results of treatment of 248 patients with an acute pancreatitis (AP) are analyzed. Conservative therapy was effective in 178 of them. Mortality was 0.3%. Surgical intervention was done in 64 patients, including 25 with AP, of them 2 (8%) have died; 27--with destructive AP, after cholecystectomy, drainage of bursa omentalis and abdominal cavity 15 (55.5%) died. Pancreatic resection, necrotomy, programmed relaparotomy with permanent necrotomy of pancreas and retroperitoneal cellular tissue were conducted in 17 patients, 3 (17.6%) died.     

Functional results of surgical repair of chronic duodenal insufficiency associated with duodenal ulcer

The results of 312 patients examination in late follow-up period after conduction of the organ preserving intervention, gastric resection and reconstructive operation with chronic duodenal insufficiency correction, concurrent with duodenal ulcer, its acute complications, postvagotomy and postresection syndrome are adduced. An excellent and good result was noted in 70.2% of patients, fair--in 23.4%, bad--in 6.4%.     

Five-year follow-up of a prospective randomised multi-centre trial of weekly chemotherapy (CAPOMEt) versus cyclical chemotherapy (CHOP-Mtx) in the treatment of aggressive non-Hodgkin''s lymphoma. Central Lymphoma Group

Benign tumors of the pancreatic head are normally treated by a partial duodenopancreatectomy. This operation has been developed for the treatment of malignant alterations in the pancreatic head and includes resection of the gastric bowel, duodenum and common bile duct. The aim of this study was to evaluate whether the less radical duodenum-preserving pancreatic head resection is a suitable surgical procedure in the treatment of benign pancreatic head tumors. From May 1982 to December 1996, seven patients underwent surgical treatment for benign pancreatic head tumors. Two patients suffered from gastrinoma of the pancreatic head, four exhibited a serous or mucinous cystadenoma, and one patient suffered from an intraductal papillary-mucinous tumor in this region. All patients were treated by duodenum-preserving pancreatic head resection. The operation was easily performed with little blood loss and a low rate of complications. None of the patients had to be reoperated upon due to postoperative surgical complications. After a follow-up period of a median 3 years, six of seven patients were had no recurrence of the disease and were symptom-free. One patient who had initially been operated on for gastrinoma still exhibited high gastrin values postoperatively. The endocrine and exocrine pancreatic function was not impaired in the early and late postoperative phase as compared to the preoperative assessment. From our results, it is concluded that duodenum-preserving pancreatic head resection is an adequately radical, yet organ-preserving procedure for the treatment of benign tumors of the pancreatic head without compromising endocrine and exocrine function.     

Endoscopic therapy of pancreas divisum

Pancreas divisum is the most frequent congenital ductal anomaly of the pancreas: it occurs in 5-10% of the population. In the majority of patients, this congenital anomaly is of no clinical importance. In a certain subset of patients, however, pancreas divisum is clinically important as a cause of abdominal pain, acute recurrent pancreatitis or chronic obstructive pancreatitis. The authors, experience on endoscopic drainage of the minor papilla is reported. In the history of patient 1., three episodes of recurrent pancreatitis and permanent upper abdominal pain were explored. ERP revealed a pancreas divisum and a mild irregularity and dilation of the dorsal pancreatic duct. A 7 F stent (length: 6 cm) was implanted in the dorsal pancreatic duct following a papillotomy on the stenotic minor papilla. A repeated Lundh test revealed a 58% improvement in the exocrine pancreatic function. No recurrence of pancreatitis has been observed in spite of the moderate continuous abdominal pain. In patient 2., ERP demonstrated a pancreas divisum and a severely dilated dorsal pancreatic duct as causes of the previous permanent abdominal pain. An 8 F stent (length: 5 cm) was inserted through the minor papilla without endoscopic sphincterotomy. A significant improvement in exocrine pancreatic function (70%) ensued. No abdominal pain has since been observed. In conclusion, dorsal pancreatic duct stenting (mainly in cases involving a dilated pancreatic duct) seems to have a beneficial effect in patients with both recurrent acute pancreatitis or chronic obstructive pancreatitis evoked by pancreas divisum.     

Ultrasound-guided fine needle biopsy of pancreatic masses: results of a multicenter study

OBJECTIVE: The aim of this study was to investigate the results of ultrasound-guided fine needle biopsy of pancreatic masses in a large multicenter series. METHODS: This study collected the data of 510 patients who had a final diagnosis available and who had undergone ultrasound-guided fine needle biopsy of the pancreas. Retrieval rate, sensitivity, specificity, and overall diagnostic accuracy of the whole series, by three different bioptic procedures (cytology, histology, and cytology plus histology) were evaluated. The reliability of ultrasound-guided fine needle biopsy to allow a correct diagnosis in the different pancreatic pathologies was calculated. Finally, any complications were collected. RESULTS: For cytology, histology, and cytology plus histology, retrieval rate values were: 94%, 96%, and 97%; sensitivity was: 87%, 94%, and 94%, specificity: 100%; and diagnostic accuracy: 91%, 90%, and 95%, respectively. Ultrasound-guided fine-needle biopsy correctly diagnosed all the cases of pancreatic metastases or non-Hodgkin's lymphoma (23 of 510 cases as 5%; in eight of 23 it led to the first diagnosis of the primary tumor) and all the cases of abscesses, 97% of the cases of pseudocysts, 86% of pancreatic adenocarcinomas, 62% of cystic neoplasms, 35% of the cases of chronic pancreatitis (in this case, the bioptic procedures were reviewed), and 33% of neuroendocrine tumors. There were complications in one case of asymptomatic peripancreatic hematoma, three cases of vaso-vagal reactions, and 21 cases of pain. CONCLUSION: Ultrasound-guided fine needle biopsy of the pancreas is efficacious, without any difference between the various bioptic modalities (with the exception of chronic pancreatitis, in which histology is better). The technique is safe. Moreover, the procedure allows the identification of patients affected by pancreatic tumors other than adenocarcinoma (in our survey 5% of the total); in about one third of these patients it leads to the diagnosis of the primary tumor, thus avoiding inappropriate treatments.     

Ductal adenocarcinoma of the pancreas head: survival after regional versus extended lymphadenectomy

BACKGROUNDS/AIMS: The aim of the study was to evaluate the influence of regional versus extended lymphadenectomy on survival in patients with ductal adenocarcinoma of the head of the pancreas. From 1988 to 1996 we performed partial duodeno-pancreatectomies (Whipple procedure) combined with either regional (n = 20, group A) or extended retroperitoneal (n = 33, group B) lymphadenectomy in 53 patients with ductal adenocarcinoma of the pancreas head. METHODOLOGY: The outcome of the two groups was compared by constructing survival curves and evaluating demographic, intraoperative and histopathologic data from all patients (n = 44) with curative (R0) resections. RESULTS: For patients after R0 resection there was no significant difference in terms of survival between group A and B. Only tumor stage (p = 0.0258), portal vein invasion (p = 0.0190) and tumor grade (p = 0.0021) had a significant influence on survival, regardless of the type of operation. CONCLUSION: Our data suggest that no further improvement of the survival rate can be achieved by extended retroperitoneal lymphadenectomy, compared to regional lymphadenectomy.